Rehab Rounds : Combining Telephone Peer Counseling and Professional Services for Clients in Intensive Psychiatric Rehabilitation

Traditionally, crisis intervention has been viewed as a treatment limited to situations involving life-threatening emergencies (10). In response to our rapidly changing and more complicated society, crisis-oriented treatment now more readily applies to anyone who perceives his or her problem as needing attention without delay. Crisis services operated by mental health and other human service agencies respond to physical, verbal, and emotional abuse; violent crime; drug use; and the epidemic of AIDS and other deadly diseases by providing social services, self-help groups, and hotlines.

The meaning of crisis for persons with serious and persistent mental illness can be expanded to include a variety of stress-inducing events. They include lack of financial resources, difficulty with a roommate, arguments with family members, annoying side effects of medication, missed doctor's appointments, and other problems that occur in the course of daily living outside a hospital environment (11). Persons with mental illness are constantly challenged in solving problems to maintain clinical stability and social adjustment, yet few services are available to them in crisis situations.

In May 1994 clients who were receiving intensive psychiatric rehabilitative treatment at the Federation Employment and Guidance Service in Manhattan expressed a need for support services to be provided during weekends and holidays when the agency is closed. Their request led to the formation of a committee that included clinicians, administrators, and clients and whose purpose was to identify ways to fill this void in the treatment program. After several meetings, the committee recommended the development of a telephone peer counseling program.

The committee based their decision on a variety of factors. First, the increasing impact of managed care and health care reform has resulted in shorter inpatient stays. This change has increased the number of clinically unstable clients discharged into the community who are likely to need supports for promoting reintegration and stabilization in the community and preventing relapse. Telephone peer counseling was seen as a cost-effective means to meet the needs of these clients. Unfortunately, the amount of personnel resources devoted to outpatient mental health has not kept up with the changes in the philosophy of health care delivery. Therefore, outpatient programs may need the help of clients as sources of manpower.

Another factor cited in favor of developing the peer counseling program was its contribution to consumer empowerment. The committee members decided that the theoretical foundation for the peer counseling program would be the self-help model. From this perspective, the peer counseling role is constructed as a relationship between equals that is based on the power of shared experiences. As such, peer counseling serves a twofold purpose.

First, because mental illness contributes to increased isolation and lack of relationships, a telephone connection was seen as increasing socialization and support for both the caller and the counselor. Second, peer counseling coincides with fundamental rehabilitation principles and may enhance a client's movement toward a chosen goal. Desired outcomes include increasing a sense of purpose and human connectedness and decreasing helplessness and lack of a social role. As one of the participants on the committee said, "The power of human caring can make the difference between hope and despair."

Peer counseling training

The peer counseling program was to be operated from counselors' home phones between 5 and 9 p.m. on weekends. A ten-session peer counseling training program was developed to prepare clients for taking phone calls. (A training manual is available from the author.) The topics included distinguishing between the role of a peer counselor and that of a professional clinician, setting boundaries, documenting phone calls, recognizing emergency situations and knowing what to do about them, and identifying consumer resources, such as recreational facilities, self-help groups, and professional services. Several sessions addressed communication and active listening skills. These skills were taught using behavioral approaches such as role playing, modeling, shaping, and positive reinforcement.

The peer counselor training addressed both the tasks involved in the program and its socioemotional aspects through activities to increase skill development and foster group cohesiveness. Providing the group with handouts at each session was helpful in reducing anxiety, increasing concentration, and improving attention. Peer counselor trainees' self-esteem increased as the training sessions progressed from didactic workshops in communication and listening skills to active role playing.

Initially, trainees resisted role-playing exercises, stating that they feared making mistakes. Group discussions centering on fears of being judged enabled trainees to use their feelings of discomfort to understand the potential reactions of client callers. Although role-play scenarios were created to review skills and to identify potential concerns of callers, trainees often used role-play exercises to work through current life stressors. As a result, trainees enhanced their own coping skills and support network, as well as their communication skills.

The supportive nature of the peer counseling training also proved effective in meeting the client counselors' need to belong. At completion of the training phase, clients received a certificate, which provided tangible evidence of their progress both in achieving program goals and in personal development. Completion of the training, punctuated by a satisfactory performance on the role play used as a certification exam, helped clients to develop a sense of empowerment, a feeling of belonging to a group, an identity as a student and a worker, and the ability to have something to share with others.

The first year

During the program's first year, 11 clients volunteered for the program (clients received $2-a-day stipends on weekends when they were on call), completed the training, and received their certificates. During the year, they worked on weekends from 5 to 9 p.m. and handled 46 phone calls without a negative incident. Moreover, staff members noted that the peer counselors met their own rehabilitation goals, such as increased socialization and improved interpersonal skills, at an accelerated rate, compared with similar clients who did not participate in the peer counseling training.

An informal survey conducted by staff at the end of the first year revealed that the telephone peer counseling program was greatly appreciated by both peer counselors and callers. Peer counselors reported that their new interpersonal skills helped them advance toward their rehabilitation goals. Two peer counselors returned to full-time, competitive employment; a third completed vocational training; and another returned to part-time work and attending college. Two other peer counselors moved into more independent housing.

The client callers also reported that they benefited from the enhanced support available to them. Several callers mentioned that the peer counselor was, in effect, "the right person at the right time" for the problem they were having. For example, one client called to ask whether he should take his medication one hour late (he had forgotten to take it at the appropriate time) or just wait until the next day. The peer counselor asked the appropriate questions and gave the correct answer. Another client stated that if the peer counselor had not been available to talk to him, he would have required emergency room services. With the help of the peer counselor, the client was able to calm himself, and the crisis was averted.

Issues in implementation

As the professional coordinator of peer counseling, I found the following steps essential for design and implementation. First, the needs voiced by clients must be heard and taken seriously by professionals. Second, maintaining flexibility and responsiveness to the feedback of both clients and professionals and respecting differences between professionals and clients are key ingredients to success. Off-site, off-hours peer counseling is not the norm but a unique program that is a significant support for the intensive psychiatric rehabilitative treatment program and its goals. As clients change, needs change, and program changes must be able to meet these needs.

Unfortunately, new programs are particularly susceptible to failure, and the coordinator must educate staff and clients about the program's advantages and answer any questions to increase its chance of success. Well-meaning clinicians who enter the field of psychiatric rehabilitation to take on a nurturing, caregiving role often have mixed reactions to the idea of client empowerment. Client hostility may develop around issues of one-upmanship and confidentiality.

Initial problems among peer counselors included resistance to working with more symptomatic clients. Peer counselors also struggled with issues of carrying out a dual role. They expressed fear that the worth of the program would be minimized by both staff and other clients, projecting concerns that callers would doubt that a fellow client could do anything for them. They also expressed concern about the unclear boundaries separating the roles of the peer counselor and the professional.

Professional delivery of services and self-help may serve as complementary forms of treatment available to clients, as evidenced within the peer counseling program. Collaboration may result, providing that all parties recognize and respect the differences between these two helping modalities. Added support may increase clients' rate of improvement from professional treatment, and professional treatment may enhance a client's ability to develop external supports. Furthermore, if a potentially destabilizing situation occurs, increased supports may diminish the likelihood of a crisis or facilitate quicker recompensation with better prognosis.

According to the philosophy of the intensive psychiatric rehabilitative treatment program, peer counseling is a consumer-driven initiative focusing on the strength of shared experience and support that serves as an adjunct to rehabilitative treatment. Collaboration with professional treatment may serve to expedite clients' improvement and to foster empowerment without the expense of additional professional manpower. Government cutbacks create a real need for becoming more creative and effective in reaching hard-to-reach populations. Combining crisis theory with self-help, peer counseling keeps the person-to-person connection in the forefront of an agency's services. It provides a human approach to the many problems experienced by persons with mental disabilities who are struggling against great odds to establish and sustain a satisfying niche for themselves in the community.

Afterword by the column editors:

A unique characteristic of the telephone peer counseling service that was developed in the intensive psychiatric rehabilitative treatment program at the Federation Employment and Guidance Service is that it was requested by the clients themselves to fulfill a need they identified—to have someone available for consultation outside of regular working hours. One ideal solution for this problem would be to use a program for assertive community treatment (PACT) model (12). Unfortunately, the PACT approach is frequently not feasible due to constraints on fiscal and personnel resources. Yet by recognizing the human and technological resources that were available—clients as volunteer "prosumers" and telephones—and yoking them to a skills training approach, clients and agency staff found a way to provide after-hours outpatient services. The telephone, in particular, is an underutilized means of accomplishing outreach to clients and extending the limited services available.

Future evaluation and research will be needed to determine whether telephone peer counseling is a cost-effective means to meet the needs of persons with chronic mental illness and their families and natural support persons. This report does suggest that telephone peer counseling can serve as a natural extension of psychiatric rehabilitation, helping clients to develop problem-solving skills, exercise their interpersonal skills, and recognize the power of shared experiences.

Ms. Lane is in the private practice of social work in New York City. Address correspondence to her at 401 East 34th Street, N-9P, New York, New York 10016. Alex Kopelowicz, M.D., and Robert Paul Liberman, M.D., are editors of this column.